Issuing office

Annual Quality
Assurance Assessment
Care homes for older people
Part 1: Self Assessment
Electronic
Please fill in this form using black ink.
Using this electronic Word version: To use this form version please follow the guidelines below:x

To put text into a text entry box, click within the box to the left side.

x

To move from text entry box to another box use the tab key on your keyboard.

x

You may overtype any text you have typed by highlighting and deleting the text.

x

To mark ‘checkboxes’ point your mouse on the box and click.

To be filled in by you:
Name of your service:Your service number:
Address of your service:
Postcode:Your name:Your job title:
Your phone number:Your Email address:
Your website address:
Date that you sent the form to us: (dd/mm/yyyy)

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The completed form should be returned as an e-mail attachment to your regional CQC office. Or, if you
prefer, print off a copy and post it to us at:Care Quality Commission
National Correspondence
Citygate
Gallowgate
Newcastle Upon Tyne NE1 4PA

Eastern Region

Email: enquiries.eastern@cqc.org.uk

London Region

Email: enquiries.london@cqc.org.uk

North East Region

Email: enquiries.northeastern@cqc.org.uk

North West Region

Email: enquiries.northwest@cqc.org.uk

South East Region

Email: enquiries.southeast@cqc.org.uk

South West Region
Email: enquiries.southwest@cqc.org.uk
West Midlands
RegionEmail: enquiries.westmidlands@cqc.org.uk

Yorkshire andHumberside

Email: enquiries.yorkshirehumberside@cqc.org.uk

We have written guidance to help you when you fill in this annual quality assurance assessment. It tells
you:x

Why we are asking you to fill it inxWhat we are looking for you to say in the annual quality assurance assessmentx

What to do when you have filled it inxWhat we will do when we have received it from you

This guidance can be found on our website at: www.cqc.org.uk
We will hold and process your personal information so that we meet the Data
Protection Act 1998. You can get further information about this on our website at www.cqc.org.uk orfrom our customer services helpline on 03000 616161.

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1. The views of people who use our services
We do the following to ensure that the views of people who use our services are promoted andincorporated into what we do:
We have made the following changes as a result of listening to people who use our services:
We are planning to make these further changes as a result of listening to people who use our services:

2. Equality and Diversity
We do the following to ensure that race, gender identity, disability, sexual orientation, age, religion
and belief are promoted and incorporated into what we do:
We have made the following changes to ensure that equality and diversity has been promoted within
our service:
We are planning to make these further changes to promote equality and diversity:

3. Barriers to improvement
We have found that during the last 12 months the following issues have made it hard for us to improveas much as we would have liked:
We have tried to reduce the impact of these barriers by:

4. Value for Money
We know that we give a service that provides value for money because:

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Annual Quality Assurance Assessment
Care homes for older people
National Minimum Standards outcome area:

National Minimum Standards:

Choice of Home1, 2, 3, 4, 5 and 6(the key standards are in bold)

What we do well:

Our evidence to show that we do it well:

What we could do better:

How we have improved in the last 12 months:

Our plans for improvement in the next 12 months:

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National Minimum Standards outcome

National Minimum Standards:

area:
7, 8, 9, 10 and 11(the key standards are in bold)

Health and Personal Care
What we do well:

Our evidence to show that we do it well:

What we could do better:

How we have improved in the last 12 months:

Our plans for improvement in the next 12 months:

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National Minimum Standards outcome area:

National Minimum Standards:

Daily Life and Social Activities

12, 13, 14 and 15(The key standards are in bold)

What we do well:

Our evidence to show that we do it well:

What we could do better:

How we have improved in the last 12 months:

Our plans for improvement in the next 12 months:

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National Minimum Standards outcome area:

National Minimum Standards:

Complaints and Protection

16, 17 and 18(the key standards are in bold)

What we do well:

Our evidence to show that we do it well:

What we could do better:

How we have improved in the last 12 months:

Our plans for improvement in the next 12 months:

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National Minimum Standards outcome area:

National Minimum Standards:

Environment

19, 20, 21, 22, 23, 24, 25 and 26(the key standards are in bold)

What we do well:

Our evidence to show that we do it well:

What we could do better:

How we have improved in the last 12 months:

Our plans for improvement in the next 12 months:

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National Minimum Standards outcome area:

National Minimum Standards:

Staffing

27, 28, 29 and 30(the key standards are in bold)

What we do well:

Our evidence to show that we do it well:

What we could do better:

How we have improved in the last 12 months:

Our plans for improvement in the next 12 months:

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National Minimum Standards outcome area:

National Minimum Standards:

Management and Administration

31, 32, 33, 34, 35, 36, 37 and 38(the key standards are in bold)

What we do well:

Our evidence to show that we do it well:

What we could do better:

How we have improved in the last 12 months:

Our plans for improvement in the next 12 months:－ 123 －

Brief summary of our comments made within this Annual Quality Assurance
Assessment:
What our service does well:

How we have improved in the last 12 months:

What we could do better, and how we are going to do this:AQAA – Care homes for older people

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－ 125 －Age

GenderEthnicity

YES

NO

YES

NO

YES

NO

YES

NO

Did the person Does the person
Does the
Does the person
start using your have complex or person have have significant
service in an individual funding active family involvement withemergency?
arrangements?
or advocate health or social
support?
care
professionals?

AQAA – Care homes for older people

Ref. ofpersonusing
yourservice
YES

NO

Does the person
havecommunicationdifficulties?

Page 12Is there any additional
information you think weneed to know?

We have given you 25 rows in the form below, however you will probably not need to use them all. The guidance will tell you how many people weneed you to give us the details of. You should read the guidance before filling in these forms. It will help you understand what we want you to do,
and will explain why we want you to do it. We need this information but you can use your own format if it is easier for you. Note: In the sections
where you are required to answer ‘Yes’ or ‘No’ please use an ‘X’ to respond. For example, if a person started using your service in an
emergency place an ‘x’ in the ‘yes’ box

Additional information we would like you to give us:

－ 126 －Age

GenderEthnicity

YES

NO

YES

NO

YES

NO

YES

NO

Did the person Does the person
Does the
Does the person
start using your have complex or person have have significant
service in an individual funding active family involvement withemergency?
arrangements?
or advocate health or social
support?
care
professionals?

AQAA – Care homes for older people

Ref. ofpersonusing
yourservice
YES

NO

Does the person
havecommunicationdifficulties?

Page 13Is there any additional
information you think weneed to know?

－ 127 －Name

Ref NoAQAA – Care homes for older people

Ref NoName

Ref NoName

Ref NoName

Page 14

We would also like you to give us the names of all the people using your service (apart from the ones that you have given us above). If you support
more people than there are spaces, please include their names in the notes section at the end of the annual quality assurance assessment:

－ 128 －Name

Ref NoAQAA – Care homes for older people

Ref NoName

Ref NoName

Ref NoName

Page 15

Part 2: Dataset
Note: In the sections where you are required to answer ‘Yes’ or ‘No’ please use an ‘X’ torespond. For example, if you have portable electrical equipment, place an ‘x’ in the ‘yes’ box

About the Service:
1. Maintenance of Equipment
Has the following equipment, as applicable, been serviced or tested as recommended by
the manufacturer or other regulatory body?
Do you havethisequipment?

Date of last review
or certificate

Yes

M M Y Y Y Y

NoPremises electrical circuits
Portable electrical equipment
Lifts/stair lifts
Hoists [including portable]
Fire detection and alarm
Fire fighting equipment
Emergency lighting
Emergency call equipment
Heating system
Soiled waste disposal
Gas appliances
2. COSHH
Do you have written assessments on hazardous substances [Control of
Substances Hazardous to Health]?

Yes

No

No

N/A

3. Drugs and medication
Yes
3a

If you provide nursing care, is equipment used for disposal ofdrugs and sharps provided through a contract with a specialist
disposal service?

3b

Have any of the following controlled drugs been administered orstored in the home in the past 12 months: morphine,
dexamphetamine, diamorphine, pethidine, fentanyl,
methadone, methylphenidate?

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3c

Have any other ‘Schedule 2’ controlled drugs [not named in
Question 9b] been administered or stored in the home in thepast 12 months?

3d

Does the service obtain a stock of controlled drugs for use in thehome [instead of individually prescribed drugs for named
residents]?

3e

Have there been any serious incidents involving controlled
drugs, within the past 12 months?

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

4. Infection control

4a

Do you have an action plan to deliver best practice in prevention
and control of infection?

4b

How many of your staff have received training in prevention andcontrol of infection?

5. Nutritional Screening

5a

Do you carry out nutritional screening on everyone admitted toyour service?

5b

If so, do you repeat the screening for people at risk ofmalnutrition?

5c

Do you take actions to meet the needs of people at risk ofmalnutrition?

5d

How many of your staff have received training in malnutrition
care and assistance with eating, (including those who prepare
and serve food)?

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6. Policies & Documents
Policy/Procedure/Codes of practiceCare Homes for Older People and Adults Aged 18 - 65
Do you have thepolicy/procedure/ codein place?
Yes

No

Last review

M M Y

Y Y Y

Access to files by staff/users
Accidents to service users
Aggression toward staff
Annual development plan for quality assurance
Bullying
Communicable diseases and infection control
Clinical procedures
Code of conduct
Concerns and complaints
Continence promotion
Control of substances hazardous to healthConfidentiality and disclosure of information
Contact with/ visits by family and friends
Control, storage, disposal, recording and administration of
medicines
Dealing with violence and aggression
Death of a service user
Discharge of service users, including planned discharge,
and termination or self-discharge at short notice
Disclosure of abuse & bad practice (Whistle blowing)
Disposal of clinical waste
Emergency admission and detention Mental Health Act
1983
Emergencies and crises
Equal opportunities, diversity, and anti-oppressive
practice
Fire safety
First aid
Food safety and nutrition
Gifts to staff
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Policy/Procedure/Codes of practiceCare Homes for Older People and Adults Aged 18 - 65
Do you have thepolicy/procedure/ codein place?
Yes

No

Last review

M M Y

Y Y Y

Health and safety (Health and Safety at Work Act 1974)
EC Regulation 852/2004 and the Food Hygiene (England)
Regulations 2006
Individual planning and review
Induction and foundation training (now Common Induction
Standards)
Management of service users money, valuables andfinancial affairs
Missing service users
Moving and handlingNursing/treatment/care guardianship under Mental Health
Act Regulations 1983 and Mental Health Act Code ofPractice 1983
Physical intervention, restraint
Pressure relief
Racial harassment occurring between service users;
between staff; by staff; or by service users on staff
Record keeping
Recruitment and employment including redundancy
Referral and admission
Safeguarding adults and the prevention of abuse
Sexuality and relationships
Smoking and use of alcohol and substances by users,
visitors and staff
Staff grievance and disciplinary procedures, staff
supervision
Values of privacy, dignity, choice, fulfilment, rights andindependence
Working with volunteers

About People who use your Service
7. General Occupancy
7aNumber of people admitted in the last 12 months [not including short term/temporary

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residents]
7b

Number of short term/temporary residents in the last 12 months (specialist, wholly
respite services, put N/A)

7c

Number of permanent discharges in the last 12 months

7d

Number of placement breakdowns in the last 12 months

7e

Number of residents aged 16-17 in the last 12 months

7f

Does this service cater for children under the age of 16?

Yes

No

If yes, how many have received a service in the past 12 months?
8. Significant areas of needs
Please give the number of people with the following needs on the day this form is filled in:
Number withthis need
People who are bed fast
People who require help with dressing/undressing
People who require help with washing/bathing
People who require help going to the toilet
People who are singly incontinent [urine or faeces]
People who are doubly incontinent
People who have dementia
People who have other mental health needs
People who have a learning disability
People who have a physical disability
Day

Night

People who normally require two or more staff to help with care
People who require help/supervision/prompts to eat meals
People who have impaired vision
People who have impaired hearing
People whose first language is not English
People who have specialist communication needs
People who have alcohol dependence
People who have drug dependence

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9. Diversity of people using your service
9a Gender
Please give the number of people in each group:
FemaleMaleTransgender**Where people have been prepared to share this information voluntarily
9b Ethnicity
Please give the number of people in each ethnic group:White
BritishIrish

Any other White background

Mixed
White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background

Asian or Asian British
IndianPakistani

Bangladeshi

Any other Asian backgroundBlack or Black British
Caribbean

AfricanAny other Black background

Chinese or other ethnic group
ChineseAny other

Not known
9c Religion/faith
Please give the number of people in each group:
Christian [including Church of England, Roman Catholic, Protestant, non-Conformist, andall other Christian Denominations]None

Buddhist

Hindu

JewishMuslimSikh

Any other religion [Please state]
Not known
9d Sexual orientation
Please give the number of people in each group:
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Bisexual

Gay Man

Lesbian/Gay Woman

Heterosexual/Straight

Not known
10. Complaints, protection and other events
This section relates to the last 12 months before the day this form is filled in:
10a

Number of complaints received

10b

Percentage of complaints resolved within 28 days

10c

Number of complaints upheld

10d

Number of complaints waiting for an outcome on the day this form is filled in

10e

Number of incidents when restraint was used

10f

Number of safeguarding adults referrals made10g

Number of safeguarding adults investigations

10h

Number of referrals to the Protection of Vulnerable Adults List [POVA]

10i

Number of admissions to Accident & Emergency [or Emergency Medical Unit] but not
via a GP or consultant

10j

Number of deaths (a) at the home(b) at hospital or hospice

10k

Number of people admitted to your home in the last 12 months who have sincedeveloped pressure ulcers.

11. Contracts
11a

How many people, who are privately funded, have a written contract?

11b

How many people, whose care is funded by a council or health trust, have a copy of
the agreement specifying the arrangements made?

11c

Have you, or your organisation, reviewed all the contracts for people whoseplaces are privately funded?

Yes

No

11d

Do you make a copy of the latest CQC/CQC inspection report on the homeavailable to all new and existing people who use your service?

Yes

No

12. Care and Support
Please fill in for current residents including temporary absences:
1

2

3

AQAA – Care homes for older people

45Page 22－ 135 －Name of council or health body with full or
Number ofpartial funding responsibility [For people who people
are privately funded use the bottom line forcolumns 2-5 and 7-10*]

6

7Number ofpeople whocame straightfrom hospital

8

9

Number of people with Number of people
Number of people who
a council or healthwhere the care plan have been resident forbody care plan
describes daily living, 12 months or more
including restrictions
and longer term
objectives

AQAA – Care homes for older people

Number of
Number ofpeople receiving people with aa council orcare plan
health bodyassessment
before admission

10

Number of people
Number of people
where a review of the known to have had nocare plan has been
contact with family,
undertaken by theirfriends or an advocatesocial worker/carein the past 12 months
manager in the last 12
monthsPage 23－ 136 －

6

7

8

9

Number of people with Number of people
Number of people who
a council or healthwhere the care plan have been resident forbody care plan
describes daily living, 12 months or more
including restrictions
and longer term
objectives

10

Number of people
Number of people
where a review of the known to have had nocontact with family,
care plan has been
friends or an advocate
undertaken by theirsocial worker/carein the past 12 months
manager in the last 12
monthsN/A*Please provide the same information, on the bottom line of each column, for people who are
funding their own places in your home

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13. Staffing
13aNumber of shifts, in the past 3 months, which have been covered by temporary staff, or staff
from an agency:
Nursing
Care
Senior care

13b

Number of current permanent staff who have received training in safe food handling. Put X
in the box if the category isn’t applicable for your home.
Catering staff
Care staff.

13c

Do you have a staff development programme that meets the National
Minimum Standards for your service?

Yes

No

13d

Recruitment checks - Did all the people, who have started work in yourhome in the last 12 months, [Permanent; temporary; agency; volunteer]
have satisfactory pre-employment checks?

Yes

No

Notes

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APPENDIX A
ANNUAL QUALITY ASSURANCE ASSESSEMENT
Care Homes for Older People
Workforce Questions
If you have completed the relevant parts of the Skills for Care (SfC) National Minimum
Dataset for Social Care (NMDS-SC) you do not need to fill in this Appendix.
Instead go to the NMDS-SC-ONLINE website (www.nmds-sc-online.org.uk) and download the
NMDS-SC AQAA Workforce Report for your service. That report is automatically produced
from your NMDS-SC. You can send that report to us, with this AQAA, and leave thisAppendix blank.
If you have not filled in the relevant parts of SfC’s NMDS-SC, please fill in this Appendix. The
relevant parts of the NMDS-SC are the information about your service and about individual
workers.

1.

Staffing:

1a

Number of full time care staff/registered nurses

1b

Number of part time care staff/ registered nurses

1c

Number of other staff not care/registered nurses

1d

Number of hours worked by registered nurses in the 7 days prior to the
day this form is filled in

1eNumber of hours worked by care staff in the 7 days prior to the day thisform is filled in

1f

Number of hours worked by support, but not personal care, staff in the 7days prior to this day the form is filled in1g

Number of hours worked by other staff in the 7 days prior to the day thisform is filled in

1hNumber of care staff/registered nurses who have left employment in thehome in the last 12 months

1i

Number of female care staff

1j

Number of male care staff

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2.

Staff Training and Qualifications:

2a

Number of permanent care workers

2bNumber of staff who have completed the induction training expected by the
NMS (described and recommended by Skills for Care)
Number of permanent care staff with NVQ 2 level 2 or above (The NVQ is in
Care or Health and Social Care)2c3.

Staff Ethnicity:

Number of permanent care workers / registered nurses who are:White
BritishIrish

Any other White background

Mixed
White and Black Caribbean

White and Black African

White and Asian

Any other Mixed background

Asian or Asian British
IndianPakistani

Bangladeshi

Any other Asian backgroundBlack or Black British
Caribbean

AfricanAny other Black background

Chinese or other ethnic group
ChineseAny other

Not known

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